Provider Demographics
NPI:1437750262
Name:HASLAM, NATHAN (CMHC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:HASLAM
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2121
Mailing Address - Country:US
Mailing Address - Phone:801-644-6367
Mailing Address - Fax:
Practice Address - Street 1:636 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2121
Practice Address - Country:US
Practice Address - Phone:801-644-6367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4892548-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty